Part B Medicare Benefits for Medical Nutrition Therapy



Part B Medicare Benefits for Medical Nutrition Therapy

A Quick Guide to the Medicare MNT Benefit

|Covered MNT |Type 1 diabetes, Type 2 diabetes, gestational diabetes; non-dialysis kidney disease, and post kidney transplants |

|Practice Settings |Practice settings (e.g., private practice, physician offices, ambulatory clinics); hospital outpatient departments; |

| |other outpatient settings. |

| |Excluded: inpatient hospital setting; skilled nursing facilities. |

|Medicare MNT Benefit and|Through the National Coverage Determination (NCD) decision, CMS indicated the Medicare MNT benefit basic coverage |

|Diabetes Self |(year 1) = 3 hours. CMS indicated "an episode of care typically includes 1 hour of initial assessment and four 30 |

|-Manage- |minute follow-up interventions during the first year." Additional hours are considered to be medically necessary and|

|ment Training Benefit |covered if the treating physician determines there is a change in medical condition, diagnosis, or treatment regimen|

| |that requires a change in MNT and orders additional hours during that episode of care. Follow-up (year 2) = 2 hours |

| | |

| |Effective October 1, 2002, Medicare will cover DSMT (Diabetes Self-Management Training) and MNT in initial and |

| |subsequent years without decreasing either benefit as long as DSMT and MNT are not provided on the same date of |

| |service. |

| | |

| |Until October, the provisions of the final regulation are in effect regarding coordination of MNT and DSMT. |

|Medicare MNT Provider |Registered dietitian or nutrition professional who meet all the following criteria: |

|Qualifications and |BS degree in nutrition or dietetics. |

|Requirements |Completion of 900 hours of supervised dietetics practice. |

| |Licensed or certified as dietitian or nutrition professional by State in which services are performed (if State does|

| |not provide licensure or certification, meets other criteria established by Secretary). |

| |Grandfathers dietitian, nutritional professionals licensed or certified as of 12/21/00. |

|Enrolling as Medicare |To clarify which forms to complete, RDs could contact their Medicare carrier and describe their practice settings |

|Provider CMS 855I form |(and location of) in which MNT benefit is furnished, so carrier can determine required provider forms to complete. |

| | |

| |To enroll, complete and submit CMS Form 855 I, Application for Individual Health Care Practitioners form. |

| | |

| |Form can be obtained from: |

| |--Local Medicare carrier; carriers' names, addresses, phone numbers, etc. on CMS' web page |

| |Medicare/enrollment/contacts |

| | |

| | |

| |--CMS' web page Medicare/enrollment |

| | |

| | |

| |--American Dietetic Association's web page members/statecarriers |

| | |

| | |

| |--Some carriers may request copy of state license, registration certificate, or other proof of required |

| |qualifications. |

|Additional Forms for |Depending on practice setting and employment relationship, RD may also need to complete: |

|Enrollment CMS855R and |CMS 855 R Application for Individual Health Care Practitioners to Reassign Medicare Benefits form |

|855B | |

| | |

| |CMS Form 855 B Application for health Care Suppliers that Bill Medicare Carriers form |

|Medicare Provider |Upon enrollment, RD will receive PIN, which is used on MNT claims. RD may |

|Identification Number |be required to have a different PIN for: |

|(PIN) | |

| | |

| |Each practice setting situated in different fee schedule areas. |

| | |

| |Each practice setting that is under the jurisdiction of a different |

| |carrier. |

| | |

| |RDs may practice in a group. In this case the group must obtain a PIN in |

| |addition to each individual RD obtaining his/her own PIN. |

| | |

| |Medicare carrier uses these PINs in its accounting system to insure that: |

| |payment amounts are correct; payment is sent to the correct recipient (for|

| |tax reasons, among others) (e.g., RD as recipient vs. hospital as |

| |recipient). |

|Physician Referral |Physician's referral for MNT is required: |

| |Physician can be treating physician or specialist who is treating |

| |beneficiary. |

| |Referral must indicate the order for MNT, beneficiaries' diagnosis |

| |(related to covered MNT benefit), physician's Unique Physician |

| |Identification Number (UPIN) and referral must be signed by physician. |

| | |

| |Documentation by RD of furnished MNT (initial and follow-up MNT) in |

| |beneficiary's medical record. |

|MNT Protocols |When furnishing the MNT benefit, the final regulations state recognized |

| |protocols, such as those developed by the American Dietetic Association. |

| |The guides are now available for purchase on CD-Rom from American Dietetic|

| |Association. |

|CPT Codes for MNT |CPT Code 97802: MNT, initial assessment and intervention, individual, |

|benefit |face-to-face with the patient, each 15 minutes. |

| |CPT Code 97803: MNT re-assessment and intervention, individual, |

| |face-to-face with the patient, each 15 minutes. |

| | |

| |CPT Code 97804: Group MNT (2 or more persons), each 30 minutes. These |

| |time-based MNT-specific CPT codes are listed once on the claim, but |

| |multiple units of code may be entered. |

|UN-Adjusted Medicare |CMS indicated Medicare will, "Pay the lesser of the actual charge, or 85 |

|Allowed Reimburse- |percent of the physician fee schedule amount when rendered by a registered|

|ment Rates |dietitian or nutrition professional. Coinsurance is based on 20 percent of|

| |the lesser of these two amounts." |

| |Allowed payment rates have been established under the physician's fee |

| |schedule. The RD payment amount, 85% of the physician amount, without the |

| |geographic adjustment factor is: |

| |MNT CPT Code 97802 - $14.15 per 15 min. unit = $56.60 per hour (= 4 units)|

| | |

| |MNT CPT Code 97803 - $14.15 per 15 min. unit = $56.60 per hour (= 4 units)|

| | |

| |MNT CPT Code 97804 - $5.539 per 30 min. unit = $11.08 per hour (= 2 units)|

| | |

| |Medicare reimburses 80% of the approved amount after the beneficiary has |

| |reached his/her annual $100 deductible. Remaining 20% of the approved |

| |amount, known as coinsurance, is the amount the beneficiary pays |

| |out-of-pocket. |

|Adjusted Reimburse- |CMS applies a geographical adjustment factor (GAF) to the MNT rates in |

|ment Rates |regions of country; thus, rates may vary from one region to another. |

| | |

| |Refer to American Dietetic Association's web site for GAFs and the |

| |adjusted MNT rates. |

|MNT Claims |RD must be Medicare provider to submit MNT claim for Medicare |

| |reimbursement. |

| | |

| |Beneficiary must have Part B insurance. |

| | |

| |MNT must be billed on HCFA 1500 form (can be purchased at office supply |

| |stores) |

| |Key data elements required on claim (but not limited to): Beneficiary |

| |information (including Medicare ID number); RD's name and Medicare PIN; |

| |referring physician's name and UPIN; RD's usual and customary MNT fee; |

| |CPTcode and number of units of code billed; ICD-9 diagnosis code(s); place|

| |of service code; dates of service; and beneficiary's signature *. |

| |* In lieu of signing claim, beneficiary may sign a statement that is |

| |retained in provider's file. Patient's signature authorizes release of |

| |medical information necessary to process claim. "Signature on file" is |

| |then printed on claim. |

| |Provider must send MNT claim to the local Medicare carrier. |

| | |

| |Carrier reimburses the provider directly for MNT services rendered. |

|Medicare Provider Fee |RDs should establish a fee schedule for their MNT services. |

|Setting, Billing |A fee schedule should be used for all patients, including Medicare |

|Requirements and Payment|beneficiaries. |

|Regulations |RD who is Medicare provider charges beneficiary her/his usual and |

| |customary MNT fee. |

| | |

| |A beneficiary may have more than one type of insurance or coverage that |

| |will pay for services and procedures before, or along with, Medicare. The |

| |RD or hospital billing department must determine if a private insurance |

| |plan should be billed first before Medicare. Here Medicare is the |

| |secondary insurer. |

| | |

| |If no other insurance exists, and beneficiary qualifies, RD bills Medicare|

| |and "accept assignment" with regard to payment for MNT. Accepting |

| |assignment means: |

| |RD must accept Medicare approved payment as payment in full for MNT. |

| |RD must collect the co-payment and any unmet deductible from beneficiary. |

| |RD cannot bill beneficiary, or his/her secondary insurance for difference |

| |between RD's usual and customary fee and Medicare's approved payment |

| |amount. |

| |If the beneficiary has secondary insurance, that policy may cover Medicare|

| |deductible and/or coinsurance amounts |

|Billing For MNT not |Medicare Part B cannot be billed for non-covered MNT, nor can RD bill |

|covered under Medicare |Medicare for non-covered MNT as "incident to physician's services". |

|Part B |Only the client may be billed for MNT that is not currently covered under |

| |Medicare Part B. |

| |If client has secondary insurance, he/she may submit claim to insurance; |

| |plan may/may not cover the MNT. |

|When RD Does Not Become |If RD does not become Medicare provider, she/he cannot furnish the covered|

|Medicare Provider |MNT benefit to Medicare beneficiaries |

| |In this case, RD should refer beneficiary to RD who is a Medicare |

| |provider. |

| |RD who does not enroll to become Medicare provider cannot bill the |

| |Medicare beneficiary or Medicare. |

| | |

| |If RD still wishes to furnish MNT for diabetes or non-dialysis kidney |

| |disease to Medicare beneficiaries, RD must opt out of Medicare by entering|

| |into a private contract with each beneficiary: |

| |CMS delineates regulations for opting out. |

| | |

| |Opt out period is for two years. |

| | |

| |RD must fully understand all ramifications of opting out. |

| | |

| |The American Dietetic Association's web page includes additional details |

| |on opting out; Medicare carrier's web pages may also provide opt out |

| |information. |

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